结节性甲状腺肿再次手术原因分析及对策

目的探讨结节性甲状腺术后再次手术的原因及其对策,降低结节性甲状腺再次手术率。方法对吉林大学中日联谊医院近5年结节性甲状腺术后再次手术的81例患者临床资料进行回顾性分析。结果本组81例患者,平均复发年龄52.4岁,术后诊断结节性甲状腺肿复发53例,结节性甲状腺肿继发甲状腺功能亢进4例,结节性甲状腺肿合并甲状腺癌17例,结节性甲状腺肿合并甲状腺炎7例。结论结节性甲状腺肿术后再次手术原因有:结节性甲状腺肿复发;结节性甲状腺肿合并甲状腺癌;结节性甲状腺肿继发甲状腺功能亢进;结节性甲状腺肿恶变;结节性甲状腺肿合并甲状腺炎。预防再次手术的措施及再手术体会:强调首次结节性甲状腺肿手术应当规范化,避免行肿物切除或甲状腺局部切除术,重视术中探查防止遗漏病变,术前、术中尽量明确病变性质,术中重点是避免喉返神经和甲状旁腺损伤,术后定期随访,规范化治疗。术后甲状腺素片或L-T4替代治疗,降低复发率。     

复发性结节性甲状腺肿原因及再手术技巧探讨

目的探讨如何降低手术治疗复发性结节性甲状腺肿的主要并发症。方法回顾分析了手术治疗51例复发性结节性甲状腺肿的临床资料。结果51例复发性结节性甲状腺肿再次手术后,1例患者出现声带麻痹,2例患者甲状腺功能低下,3例患者出现一过性的四肢麻木。结论复发性结节性甲状腺肿再次手术的并发症明显高于首次手术。完善的手术前准备,术中必须小心细致,丰富的经验是降低并发症发生率的关键。     

超声对结节性甲状腺肿的诊断及鉴别诊断价值

目的分析结节性甲状腺肿的声像图特征及相应的病理学基础,探讨结节性甲状腺肿的超声诊断要点及鉴别诊断。方法对经手术病理证实的203例结节性甲状腺肿、97例甲状腺腺瘤及56例甲状腺癌的声像图特点进行回顾性分析。结果结节性甲状腺肿的超声诊断符合率最高,占91.1%(185/203);甲状腺双叶不规则肿大、病灶多发、结节内部回声复杂以及结节之间无正常甲状腺组织是诊断结节性甲状腺肿的重要指标。结论超声对结节性甲状腺肿的诊断及鉴别诊断具有重要价值。     

136例巨大结节性甲状腺肿手术结果分析

目的 分析巨大结节性甲状腺肿手术结果，探讨手术并发症的预防和治疗。方法 采用回顾性分析方法．收集1991—2006年间在哈尔滨医科大学第一临床医学院普外科采用甲状腺大部切除术或甲状腺次全切除术的巨大结节性甲状腺肿患者的临床资料，分析手术并发症产生的原因。结果 巨大结节性甲状腺肿患者136例．术后发生喉返神经损伤5例（3．7％），切口内出血2例（1．5％），甲状旁腺损伤3例（2-2％），喉上神经损伤1例（0．7％）。结论 术前充分准备，选择合适麻醉方式，运用综合无血手术野操作，能够预防巨大结节性甲状腺肿手术并发症的发生。     

老年结节性甲状腺肿伴甲状腺癌的诊治

目的总结老年患者结节性甲状腺肿中恶性肿瘤的发生率、病理类型、有效的诊断方法及于术疗效的随访结l粜，以提高对老年结节性甲状腺肿恶变可能的认识。方法选取老年人结节性甲状腺肿恶变患者68例，就其病理类型、术前检查结果及手术方法及预后进行分析。结果同期老年甲状腺癌68例中，多结节伴癌变20例，占29．4％，其中乳头状癌14例，滤泡癌6例；均行手术治疗，术后随访4～66个月，未发现甲状腺癌局部复发或远处转移。结论老年甲状腺多发结节伴甲状腺癌者，以乳头状癌多见，全部与良性结节并存。术前B超检查结合术冰冻切片有一定的诊断价值。     

非毒性多结节性甲状腺肿的体液免疫和细胞免疫现象

在部分地方性甲状腺肿患者的病理切片中发现局灶性淋巴细胞浸润,亦有部分患者同时存在抗甲状腺球蛋白抗体。过去对甲状腺机能亢进和桥本氏甲状腺炎的免疫研究很多,但体液免疫及细胞免疫在非毒性多结节性甲状腺肿发病中的作用至今未明。作者对14例非毒性多结节性甲状腺肿患者及10名正常人进行血液中细胞免疫及体液免疫指标试验。所有受试者甲状腺机能正常,并排除桥本氏甲状腺炎。非毒性结节性甲状腺肿患者的 IgA 水平较对照组高,由于没有发现其他体液免疫证据,抗甲状腺球     

甲状腺非霍奇金淋巴瘤的临床分析

目的探讨甲状腺非霍奇金淋巴瘤的诊断及治疗。方法回顾性分析深圳市三家市级医院2005~2016年手术治疗的甲状腺非霍奇金淋巴瘤15例患者的临床资料。结果术前诊断结节性甲状腺肿8例(53.3%),诊断结节性甲状腺肿合并乔本氏甲状腺炎7例(46.7%)。误诊率100%。全部行手术治疗,术后经免疫组化诊断,其中CD20(+)15例(100%)。随访1~10年,死亡9例(60.0%)。结论对于结节性甲状腺肿和并乔本氏甲状腺炎老年患者,应高度怀疑甲状腺非霍奇金淋巴瘤。早期穿刺活检行病理免疫组化(CD20)检查很必要。     

复发性结节性甲状腺肿再次手术临床分析

目的探讨结节性甲状腺肿术后复发再次手术治疗的安全性,减少手术并发症。方法回顾分析32例复发性结节性甲状腺肿再次手术的临床资料。结果出现并发症4例,发生率为12.5%,其中喉返神经损伤2例,喉上神经损伤1例,甲状腺功能低下1例,经治疗后全部恢复,无永久性损伤。结论复发性结节性甲状腺肿再次手术在严格掌握适应症、选择适宜手术方式的情况下安全可行,术中操作小心仔细,可减少并发症的发生。     

结节性甲状腺肿60例外科治疗体会

手术是治疗结节性甲状腺肿的重要手段,但手术并发症如喉返神经、喉上神经、甲状旁腺损伤及甲状腺功能减退等较多。为提高结节性甲状腺肿的治疗水平,我们回顾性分析了2009年1月至2010年12月收治的60例结节性甲状腺肿患者的临床资料,现将治疗经过总结报道如下。     

高频超声诊断结节性甲状腺肿63例分析

目的分析结节性甲状腺肿的高频超声表现,提高超声诊断结节性甲状腺肿的水平。方法回顾分析63例经手术病理证实的结节性甲状腺肿高频超声表现。结果结节性甲状腺肿超声表现主要为甲状腺双侧叶非对称肿大,结节多为多发,结节内部回声不均匀,部分伴有囊性变,结节内可见钙化,结节边界清,无包膜或包膜不完整,无晕环,结节之间无正常甲状腺组织,结节周边及内部血流信号不丰富。结论结节性甲状腺肿的高频超声表现多样,具有一定特征性,超声是诊断结节性甲状腺肿的一种重要方法。     

Toxic multinodular goiter

OBJECTIVES: We report a series of 70 patients with toxic multinodular goiter (TMNG) and analyze results after surgical removal. PATIENTS AND METHODS: Over a 15-year period, patients underwent thyroid surgery for TMNG. The large majority, 85.5% were women and mean age was 40 years. All patients had had goiter for more than 5 years. Clinical signs of toxicity were present in all patients, 100% presented tachycardia and palpitations. Nodules were identified at ultrasound in 95% of the patients and at scintigraphy in 90%. Serum T4 was elevated in 40 patients and THS was depressed in all. The chest x-ray revealed a plunging goiter in 10 patients. All patients were given medical treatment prior to surgery for total thyroidectomy in 15 and subtotal thyroidectomy in 55. There were no deaths. Two patients developed hematomas, to suffered injury to the recurrent nerve, and five developed acute hypoparathyroidism. Three cases of thyroid carcinoma were observed. DISCUSSION: TMNG is an indication for radical treatment, generally surgery. Medical treatment is required in preparation for surgery. Total thyroidectomy is used increasingly, providing a definitive cure of toxic hyperthyroidism and avoiding the risk of recurrence. With increasing surgical skill, the risk of recurrent or parathyroid injury is greatly decreased.     

Thyroid cancer in hyperthyroidism: incidence rates and value of ultrasound-guided fine-needle aspiration biopsy in this patient group

Three hundred and thirty-three hyperthyroidism cases were retrospectively investigated to provide information about the association between hyperthyroidism and thyroid cancer. There were 112 cases of toxic multinodular goiter (TMNG), 77 cases of toxic nodular goiter (TNG) and 144 cases of Graves' disease (GD). All nodules detected in GD patients, all nodules greater than 1 cm diameter in nodular goiter patients, nodules 5-10 mm size diameter if they had calcification were fine-needle biopsied (FNAB) under ultrasound guidance (US-guided), and a total of 612 such biopsies were performed. The biopsy samples were cytologically assessed as benign (no.=552; 90.2%), suspicious (no.=6; 1.1%), malignant (no.=13; 2.1%), or inadequate for diagnosis (no.=41; 6.7%). All patients with a biopsy diagnosis of malignant or suspicious nodules underwent surgery. Histological examination confirmed the diagnosis of thyroid cancer in all 13 (2.1%) patients with malignant FNAB findings. Papillary thyroid carcinoma (PTC) was identified in 2 patients with TMNG (%1.8), 5 with TNG (%6.5) and 5 with GD (%3.5). Metastatic follicular thyroid carcinoma (FTC) was identified in a patient with TNG. Thyroid malignancy (micro- or macrocarcinoma) was diagnosed pre-operatively in all 13 cases by US-guided FNAB. Thyroid cancer was diagnosed in 6 (5.5%) of the 109 nodules detected in the TNG group, 2 (0.44%) of the 452 nodules detected in the TMNG group, and 5 (9.8%) of the 51 nodules detected in the GD group. Two (2.6%) of the 77 functioning nodules in the TNG patients were malignant, but none of the 402 functioning nodules in the TMNG patients was malignant. In patients with hyperthyroidism, US-guided FNAB is useful for detecting thyroid cancer in nodules greater than 5 mm diameter before radioiodine therapy or surgery.     

Sodium/iodide symporter (NIS) and pendrin are expressed differently in hot and cold nodules of thyroid toxic multinodular goiter.

OBJECTIVE: The expression of two iodide transporters, the sodium/iodide symporter (NIS) and pendrin, was analyzed in thyroid tissues of patients with toxic multinodular goiter (TMNG) and non-toxic multinodular goiter (MNG). METHODS: The levels of NIS and pendrin proteins were analyzed in total protein extracts from nodular and non-nodular tissues by Western blot. RESULTS: In tissue samples from TMNG, we found an increased expression of NIS (2.5-fold) in the hot nodules, and similar levels between cold nodules and non-nodular tissues. In contrast, the levels of pendrin were slightly increased in both hot and cold nodules from TMNG, and decreased (about twofold) in cold nodules from MNG. We also noticed that there was no relationship between NIS and pendrin expression. CONCLUSIONS: Our data demonstrate that hot nodules from TMNG express a higher number of iodide transporters (mainly NIS), whereas cold nodules from TMNG, but not from MNG, show levels of the two proteins comparable with normal tissue, suggesting a role in vivo of TSH in maintaining the expression of NIS and pendrin protein in normal thyroid tissue. Finally, different mechanisms are involved in the regulation of NIS and pendrin expression.     

Altered responsiveness to thyrotropin in thyroid slices of Graves' disease preoperatively treated with excess iodide.

In a previous paper, we demonstrated that the acute administration of excess iodide inhibits the adenylate cyclase-cAMP system in mouse thyroid lobes. In the present study, we examined whether presurgical therapy with stable iodide reduces the responsiveness to TSH in thyroid tissues from patients with Graves' disease. Eight patients with Graves' disease were presurgically treated with methimazole and stable iodide and six were given methimazole alone. Normal tissues from five patients with thyroid nodules were also tested. We have found that stimulation by TSH (5 and 50 mU/ml) of cAMP formation in thyroid slices from patients preoperatively treated with methimazole and iodide is significantly less than in slices from patients treated with methimazole alone. Similar observations were also made with other thyroid stimulators, such as prostaglandin E2 and 4-methylhistamine. Furthermore, thyroid slices from patients treated with methimazole alone responded to TSH to the same degree as slices of normal tissues. The data suggest that one of the reasons for the hyporesponsiveness to TSH in thyroids from patients with Graves' disease is preoperative treatment with stable iodide.     

Germline polymorphism of codon 727 of human thyroid-stimulating hormone receptor is associated with toxic multinodular goiter.

Toxic multinodular goiter (TMNG) represents a frequent cause of endogenous hyperthyroidism, affecting 5-15% of such patients (with higher frequencies reported in iodine-deficient areas of the world). Although mutations of human TSH receptor (hTSHR) have been described in autonomously functioning thyroid nodules (AFTN), the role of such mutations in the pathogenesis of TMNG remains unclear. To search for alterations of hTSHR in AFTN and TMNG, we performed bidirectional, dye primer automated fluorescent DNA sequencing of the entire transmembrane domain and cytoplasmic tail of hTSHR (TMD+CT-hTSHR) using DNA extracted from nodular regions of 24 patients with TMNG and 7 patients with AFTN. Eight of the 24 patients (33.3%) showed heterozygote polymorphism of codon 727 on the cytoplasmic tail of hTSHR with an amino acid substitution of aspartic acid to glutamic acid. Three of 24 (12.5%) patients with TMNG were found to carry a heterozygote mutation of codon 703, resulting in substitution of alanine with glycine. One patient had multiple heterozygote mutations including I606M (Ile to Met), A703G (Ala to Gly), Q720E (Gln to Glu), and D727E (Asp to Glu). Two patients exhibited silent polymorphism of codons 460 and 618. We found no mutation of the TMD+CT-hTSHR in 7 patients with AFTN, except for a silent polymorphism of codon 460 in 1. DNA fingerprinting of codon 727 using restriction enzyme NlaIII and genomic DNA confirmed the sequencing results in all cases, indicating that the sequence alterations were not somatic in nature. This technique was also used to examine peripheral blood genomic DNA from 52 normal individuals and 49 patients with Graves' disease; 33.3% of TMNG (P = 0.019 vs. normal subjects), 16.3% of Graves' disease patients (P = 0.10 vs. normal subjects), and 9.6% of normal individuals were heterozygous for the D727E polymorphism. Expression of the D727E hTSHR variant in eukaryotic cells (COS-7) resulted in an exaggerated cAMP response to TSH stimulation compared to that of the wild-type hTSHR. These findings indicate that a germline polymorphism of codon D727E of hTSHR is associated with TMNG, suggesting that its presence is an important predisposing genetic factor in the pathogenesis of TMNG.     

甲状腺结核的诊断和治疗

目的　探讨甲状腺结核的诊断与治疗。方法 对48例经手术和病理证实的甲状腺结核进行回顾性分析。结果 术前大多数误诊为甲状腺腺瘤,少数诊断为甲状腺癌、甲状腺炎,偶有怀疑本病者。病灶切除32例,腺叶切除6例,双侧次切4例,颈清3例,峡部切除3例,切排引流3例。抗痨治疗9～12个月治愈。随访1～22年,未见复发。结论 针刺细胞学检查有助于甲状腺结核的诊断。治疗首选药物抗痨。对弥漫性肿大性质未定者可行峡部切除,干酪型周围已形成脓肿者,可行脓肿切排引流,术后用抗结核药局部灌洗。     

Prevalence of incidental thyroid cancer and its ultrasonographic features in subcentimeter thyroid nodules of patients with hyperthyroidism

In patients, who undergo surgery for hyperthyroidism, many cases of incidental thyroid cancer (ITC) have been detected. In the literature, there is no study about ITC in subcentimeter nodules in these patients. We performed this study to determine the frequency of ITC in subcentimeter nodules and ultrasonographic features that can predict malignancy in the patients with hyperthyroidism. We retrospectively reviewed our database about 3114 patients, who underwent thyroidectomy in our hospital. Among 869 patients (27.9%), who were operated because of hyperthyroidism, we enrolled 337 patients, who underwent total thyroidectomy and had subcentimeter nodule [59 Graves’ disease (GD) 98 subcentimeter nodule; 278 toxic multinodular goitre (TMNG), 359 subcentimeter nodule], in this study. Twenty-five nodules with ITC and 432 benign nodules have been detected and compared for ultrasonographic (US) features. Incidental thyroid cancer detection ratio was 5.4% [10.2% (10/98) in subcentimeter thyroid nodules in individuals with GD, and 4.1% (15/359) in individuals with TMNG, P = 0.018)]. Significant differences have been observed between the groups in terms of microcalcification in US examination of malign and benign subcentimeter thyroid nodules and the ratio of anterioposterior diameter to transverse diameter (A/T) ≥1 [(OR = 5.172; 95% CI: 1.495–17.886, P = 0.015), and (OR = 5.930; 95% CI: 1.531–22.971, P = 0.007), respectively]. We detected a higher incidence of ITC in subcentimeter thyroid nodules in GD compared to TMNG. US examination of subcentimeter nodules in hyperthyroid individuals has indicated that microcalcification and ratio of A/T ≥1 are the parameters that predict malignancy.     

脊髓髓内肿瘤显微外科治疗

目的探讨脊髓髓内肿瘤显微手术治疗方法和疗效。 方法回顾性分析海南省人民医院神经外科自2014年6月至2019年6月收治的17例经显微手术治疗的髓内肿瘤患者的病例资料,其中肢体麻木为首发症状13例,有肢体运动功能障碍9例,大小便功能障碍2例,腰背部疼痛2例,痛温觉分离者1例,呼吸困难1例,肌肉萎缩1例。所有患者在术前均行MRI平扫+增强扫描明确髓内占位性病变。全部病例采取全椎板切开术后复位固定。对患者术后病理以及术前、术后症状体征和随访复发情况进行总结,评价外科显微手术治疗髓内肿瘤的效果。 结果本组患者中,11例室管膜瘤10例全切,1例次全切除;2例星形细胞瘤1例全切除,1例次全切除;表皮样囊肿、血管母细胞瘤、胶质母细胞瘤术后转移各1例均全切除;1例炎性组织部分切除。术后症状改善11例,1例术前双下肢瘫和大小便失禁,术后无变化,5例术后症状加重,经康复治疗后2例完全恢复,2例留有轻度功能障碍,1例仅轻微改善,遗留有中度功能障碍,没有死亡病例。17例随访0.1~4.5年,2例肿瘤复发,1例再次手术,1例转放射治疗。 结论对于不同病理和性质的髓内肿瘤采取不同的显微手术方法和手术技巧,获得较好的成功率。术前症状较重者,预后较差。因此,显微外科手术是脊髓内肿瘤有效、安全的治疗方法。     

Coincidence of hot thyroid nodules and primary hyperparathyroidism.

Hyperthyroidism is frequently associated with hypercalcemia, which usually subsides after successful treatment of hyperthyroidism. Moreover, thyroid nodules are frequently detected by preoperative thyroid ultrasound in patients with primary hyperparathyroidism. Sensitised by the observation of a patient with coexisting hyperthyroidism and hyperparathyroidism we prospectively evaluated thyroid nodules in euthyroid patients with hyperparathyroidism by thyroid scintigraphy. Whereas the first patient with hyperparathyroidism was hyperthyroid the subsequent four patients with hyperparathyroidism and thyroid nodules had normal fT3 and fT4. Two patients had hypercalcemia and nephroureterolithiasis. Three patients suffered from hypercalcemia and bone pain due to osteoporosis. In the hyperthyroid patient hypercalcemia persisted after euthyroidism was achieved intact parathyroid hormone was found to be elevated. Subsequently, thyroid nodules, detected by preoperative ultrasound in four euthyroid patients with primary hyperparathyroidism, were identified as compensated hot nodules by thyroid scintigraphy. All patients underwent combined subtotal thyroidectomy and parathyroid resection. Histology showed hyperplastic parathyroid glands in one patient and a single parathyroid adenoma in four cases. Postoperatively calcium and PTH levels returned to normal and TSH levels increased in all patients. Persistence of hypercalcemia after successful treatment of hyperthyroidism should be reason for the determination of parathyroid hormone. Thyroid nodules detected by preoperative ultrasound in patients with hyperparathyroidism living in areas of iodine deficiency should be further evaluated by scintigraphy even if TSH is normal. In the case of hot thyroid nodules both parathyroid and partial thyroid resection should be performed.     

302例老年甲状腺手术临床分析

目的探讨近十年老年甲状腺外科疾病的发病情况、临床病理特点和诊治经验。方法回顾性分析1999年～2008年华东医院收治≥65岁老年甲状腺手术病人的临床病理资料。结果302例病人,年龄65～88岁,平均年龄（71．1±5．2）岁,男女比为1：2．15,多发结节242例,双侧结节224例。并存2种及以上病变占46．0％,结节性甲状腺肿190例,甲状腺腺瘤157例,甲状腺恶性肿瘤40例,甲状腺炎性疾病21例。甲状腺癌中,Ⅰ期20例,Ⅱ期6例,Ⅲ期2例,Ⅳ期10例。乳头状癌增加,结节性甲状腺肿手术病人发现微灶癌增加。结论老年甲状腺外科疾病有其临床和病理特点。应采取正确的外科诊治原则,改善预后。老年人通常可耐受各种甲状腺手术。